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Enrollment/Change Form

Enroll in Group Check It Out Automatic Withdrawal Program
Change Bank Account Information

Effective Date:

May change due to receipt date

Cancel Group Check It Out Automatic Withdrawal Program

Effective Date:

May change due to receipt date

Please choose (applies to choice above)

Applies to all subgroups (otherwise provide a list of specific subgroups)
Applies to subgroup(s) listed below

Group Information

* Group Name

* Group Number/ID

As it appears on your bill/invoice

* Subgroup Number(s)

* Group Administrator's Telephone Number

Financial Institution Information

Please choose the type of account

Checking
Savings Account

Name of Financial Institution

ABA Number

Confirm ABA Number

Bank Account Number

Confirm Bank Account Number

Name on Bank Account

By completing this form, I/we authorize Capital BlueCross and its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company®, and Keystone Health Plan® Central, and the financial institution named above, to deduct the amount of the premium for health care coverage from our account on the designated day and transfer such amount directly to Capital BlueCross. If the designated day is a holiday, the premium payment will be deducted on the next business day. We agree to maintain sufficient funds in the account to permit these deductions. If the account does not have sufficient funds at the time of transfer, I/we understand that our Capital BlueCross health care coverage may be cancelled.

By typing my full name below and submitting this form, I understand that I am creating an "Electronic Signature" that carries the same legal obligations of a written signatureName.